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Journal of Gastrointestinal Surgery

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01-11-2008 | ssat poster presentation

Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis

Authors: Bilal Kharbutli, Vic Velanovich

Published in: Journal of Gastrointestinal Surgery | Issue 11/2008

Abstract

Background

The management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5–15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients.

Methods

A decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality.

Results

One-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality.

Conclusion

LCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%.

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Title: Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis
Authors: Bilal Kharbutli
Vic Velanovich
Publication date: 01-11-2008
Publisher: Springer-Verlag
Published in: Journal of Gastrointestinal Surgery / Issue 11/2008
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-008-0624-6

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis

Abstract

Background

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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